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BRONCHIAL (TRACHEAL) - High
pitch, Loud tone, Inspiration < expiration, Harsh, hollow tubular, Trachea and larynx
BRONCHOVESICULAR - Moderate pitch, Moderate tone, Inspiration = expiration, Mixed, Over major bronchi where fewer alveoli are located: posterior,
between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces
VESICULA - Low pitch, Soft tone, Inspiration > expiration, Rustling, like the so und of the wind in the trees, Over peripheral lung fields where air
flows
through smaller bronchioles and alveoli
BRONCHIAL (TRACHEAL) - Trachea and larynx, High, Loud, Inspiration < expiration, Harsh, hollow tubular.
BRONCHOVESICULAR - Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces, Moderate, Moderate, Inspiration = expiration, Mixed.
VESICULAR - Over peripheral lung fields where air flows
through smaller bronchioles and alveoli, Low, Soft, Inspiration > expiration, Rustling, like the sound of the wind in the trees.
Restlessness, tachypnea, tachycardia, and diaphoresis
Rationale: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue.
The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?
a.
Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
b.
Rasping cough, thick mucoid sputum, wheezing, and bronchitis
c.
Productive cough, dyspnea, weight loss, anorexia, and tuberculosis
d.
Fever, dry nonproductive
cough, and diminished breath sounds
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?
a. Family history, hypertension, stress, and age
b. Personality type, high cholesterol, diabetes, and smoking
c. Smoking, hypertension, obesity, diabetes, and high cholesterol
d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol
The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck?
A. Flexion, hyperextension, rotation and lateral bending
B. Rotation, supination, inversion, flexion
C. Lateral bending, abduction, adduction, forward flexion
D. Eversion, pronation, external rotation, hyperextension
The nurse is charting on a client's eye assessment and notes PERRLA. What does this stand for?
A. Pupils Equal, Rigid, React to Light, and Accessible
B. Pupils Even, Right, React to Light, and Accommodation
C. Pupils Equal, Round, React to Light and Accommodation
D. Pupils Even, Rigid, Restrict from Light, and Accommodation
The nurse is assessing a client's neck ROM (Range of Motion). The nurse would correctly expect the client to be able to perform which movements with the neck?
A. Eversion, pronation, external rotation, hyperextension
B. Flexion, hyperextension, rotation and lateral bending
C. Rotation, supination, inversion, flexion
D. Lateral bending, adduction, abduction, forward flexion
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Terms in this set (109)
Increased tactile fremitus would be evident in an individual who has which of the following conditions?
Pneumonia
Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia).
Which of the following voice sounds would be a normal finding?
The "eeeee" sound is clear and sounds like "eeeee."
A normal finding from voice sounds is egophony—"eeeee" heard through the stethoscope clearly.
The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of older adults cause
decreased surface area for gas exchange.
The histologic
changes result in less surface area for gas exchange.
Stridor is a high-pitched, inspiratory crowing sound commonly associated with
upper airway obstruction.
Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.
Percussion of the chest is
helpful only in identifying surface alterations of lung tissue.
Percussion detects only the outer 5 to 7 cm of tissue; it does not penetrate to reveal any change in density deeper than that.An abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Percussion findings (resonant notes) may be modified by a muscular chest wall of an athlete or subcutaneous tissue of an obese person. Resonance is a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue.
Which of the following is a clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD)?
Prolonged expiration
A person with chronic obstructive lung disease commonly experiences normal inspiration but prolonged expiration to overcome the increased airway resistance.
When auscultating lung sounds, it is important for the nurse to do which of the following?
Tell the patient to stop the assessment if he/she begins to feel dizzy.
It's important to instruct the patient to let you know if they are beginning to feel dizzy during auscultation assessment as this is an early sign of hyperventilating. Must listen to full inspiration and expiration cycle and do not move quickly through the assessment as this will lead to dizziness, hyperventilation, and could cause the patient to faint. Lung sounds must be compared in each spot between both lungs. Listening to all fields in one lung prevents comparison. Anterior auscultation includes 5 spots on each side. Posterior auscultation includes 9 spots on each side.
Inspiration is primarily facilitated by which of the following muscles?
Diaphragm and intercostal
The major muscle responsible for inspiration is the diaphragm. Intercostal muscles lift the sternum and
elevate the ribs, making them more horizontal; this increases the anteroposterior diameter.
An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n)
increase in estrogen.
The increase in estrogen level during pregnancy relaxes the chest cage ligaments. This allows an increase in the transverse diameter of the chest cage by 2 cm, and the costal angle widens.
When preparing to complete thorax and lung objective assessment of an infant or child, the nurse should do which of the following?
-Allow the caregiver to hold the infant.
-If infant is sleeping, perform auscultation before doing any other objective assessments.
-Warm the stethoscope between your hands before placing on the infant.
Describe the most important points about the health history for the respiratory system.
• Do you have a cough? When did it start? Cough up any phlegm or sputum?
• Ever had shortness of breath or hard breathing spells?
• Any chest pain with breathing?
• Any past history of lung diseases like bronchitis, emphysema, asthma, or pneumonia?
• Do you smoke cigarettes or use any kind of tobacco? How many packs per day do you smoke? For how long?
Describe the pleura and its function.
are thin, slippery membranes that form an envelope between the lungs and the chest wall. The visceral pleura lines the outside of the lungs, dipping down into the fissures; the parietal pleura lines the inside of the chest wall and diaphragm and is continuous with the visceral pleura.
The pleural cavity contains a few milliliters of lubricating fluid, which lubricates the lungs during respiration. The negative pressure within
the pleural cavity holds the lungs tightly against the chest wall.
List the structures that compose the respiratory dead space.
The trachea and bronchi constitute the respiratory dead space, or space that is filled with air but is not available for gaseous exchange.
...
...
List the elements included in the inspection of the respiratory system.
Inspection of the posterior chest (thoracic cage):
o Shape and configuration of the chest wall.
o Symmetry of the thorax.
o Anteroposterior diameter.
o Neck and trapezius muscles.
o Position person takes to breathe.
o Skin color and condition.
• Inspection of the anterior chest: o Shape and configuration of the chest wall. o Costal angle. o Note facial expression (for
unconscious effort of breathing). o Assess level of consciousness. o Assess quality of respirations. o Symmetry of chest expansion. o Assess for retraction or bulging of intercostal spaces. o Assess for use of accessory neck muscles for respiration. o Assess respiratory rate.
Discuss the significance of a barrel chest.
occurs when the anteroposterior diameter is equal to the transverse diameter. Normally the
anteroposterior diameter is less than the transverse diameter. In addition, the ribs are horizontal and the chest appears as if held in continuous inspiration.
This condition occurs in chronic emphysema due to hyperinflation of the lungs.
List and describe 3 types of normal breath sounds.
descriptions of bronchial, bronchovesicular, and vesicular breath sounds.
Define 2 types of adventitious breath sounds.
Discontinuous sounds (fine, coarse crackles, atelectatic crackles, pleural friction rub)
• Continuous sounds (wheeze—high pitched and low pitched, and stridor)
The manubriosternal angle is also called ____________________. Why is it a useful landmark?
sternal angle or angle of Louis
It is a useful place to start when counting ribs
because it is continuous with the second rib.
How many degrees is the normal costal angle? ___________________
90 degree or less
When comparing the anteroposterior diameter of the chest with the transverse diameter, what is the expected ratio? What is the significance of this?
The expected ratio is 1:2 to 5:7.
When the
anteroposterior diameter is equal to the transverse diameter, the condition is called "barrel chest" and occurs with chronic emphysema.
What is the tripod position?
when the person leans forward with arms braced against the knees, a chair, or the bed. This gives the person leverage so that the rectus abdominis, intercostals, and accessory neck muscles all can aid in expiration.
List 3 factors that affect the normal intensity of tactile fremitus
(1) Relative location of the bronchi to the chest wall.
(2) Thickness of the chest wall.
(3) Pitch and intensity.
During percussion, which sound would you expect to predominate over normal lung tissue?
Resonance is the predominant sound in healthy lung tissue.
List 5 factors that can cause extraneous noise during auscultation
(1) Examiner's breathing on the stethoscope tubing.
(2) Stethoscope tubing bumping together.
(3) Patient shivering.
(4) Patient's hairy chest; movement of hairs under the stethoscope can sound like crackles.
(5) Rustling of paper gown or drapes.
Describe the 3 types of normal breath sounds.
descriptions of bronchial, bronchovesicular, and vesicular breath sounds.
The manubriosternal angle is:
a. The articulation of the manubrium and the body of the sternum.
b. A hollow, U-shaped depression just above the sternum.
c. Also known as the breastbone.
d. A term synonymous with costochondral junction.
a-The articulation of the manubrium and the body of the sternum.
Select the correct description of the left lung.
a. Narrower than the right lung with three lobes
b. Narrower than the right lung with two lobes
c. Wider than the right lung with two lobes
d. Shorter than the right lung with three lobes
b. Narrower than the right lung with two lobes
You assess a patient who reports a cough. The
characteristic timing of the cough of chronic bronchitis is described as:
a. Continuous throughout the day.
b. Productive cough for at least 3 months of the year for 2 consecutive years.
c. Occurring in the afternoon or evening because of exposure to irritants at work.
d. Occurring in the early morning.
b. Productive cough for at least 3 months of the year for 2 consecutive years.
Which of the
following assessments best confirms symmetric chest expansion?
a. Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs
b. Inspection of the shape and configuration of the chest wall c. Placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine" d. Percussion of the posterior chest
a. Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs
You are auscultating breath sounds on a patient. Which of the following best describes how to proceed?
a. Hold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field.
b. Hold the diaphragm of the stethoscope against the
chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons.
c. Listen from the apices to the bases of each lung field using the bell of the stethoscope.
d. Select the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side.
b. Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons.
Select the best description of bronchovesicular breath sounds.
a. High-pitched, of longer duration on inspiration than expiration
b. Moderate-pitched, inspiration equal to expiration
c. Low-pitched, inspiration greater than expiration
d. Rustling sound, like the wind in the trees
b. Moderate-pitched, inspiration equal to expiration
After examining a patient, you note: fever, increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with:
a. Bronchitis.
b. Asthma.
c. Pleural effusion.
d. Lobar pneumonia.
d. Lobar pneumonia.
On examining a patient's nails,
you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with:
a. Acute respiratory distress syndrome.
b. Normal findings for the nails.
c. Congenital heart disease and COPD.
d. Atelectasis
c. Congenital heart disease and COPD.
On auscultating a patient, you note a coarse, low-pitched sound during both inspiration
and expiration. This patient reports pain with breathing. These findings are consistent with:
a. Fine crackles.
b. Wheezes.
c. Atelectatic crackles.
d. Pleural friction rub.
d. Pleural friction rub.
To use the technique of egophony, ask the patient to:
a. Take several deep breaths and then hold for 5 seconds.
b. Say "eeeeee" each time the stethoscope is moved.
c. Repeat the phrase
"ninety-nine" each time the stethoscope is moved.
d. Whisper a phrase as auscultation is performed.
b. Say "eeeeee" each time the stethoscope is moved.
When examining for tactile fremitus, it is important to:
a. Ask the patient to breathe quickly.
b. Ask the patient to cough.
c. Palpate the chest symmetrically.
d. Use the bell of the stethoscope.
c. Palpate the chest symmetrically.
Pulse oximetry measures:
a. Arterial oxygen saturation of hemoglobin.
b. Venous oxygen saturation of hemoglobin.
c. Combined saturation of arterial and venous blood.
d. Carboxyhemoglobin levels
a. Arterial oxygen saturation of hemoglobin.
A pleural friction rub is best detected by:
a. Observation.
b.
Palpation.
c. Auscultation.
d. Percussion.
c. Auscultation.
A patient has a barrel-shaped chest, characterized by:
a. Equal anteroposterior transverse diameter and ribs being horizontal.
b. Anteroposterior transverse diameter of 1 : 2 and an elliptic shape.
c. Anteroposterior transverse diameter of 2 : 1 and ribs being elevated.
d. Anteroposterior transverse diameter of 3 : 7 and ribs
sloping back
a. Equal anteroposterior transverse diameter and ribs being horizontal.
Alveoli
Terminal air sacs that constitute the gas exchange surface of the lungs.
Angle of Louis
manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib
apnea
absence of breathing
Asthma
abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by inflammation, bronchospasm, wheezing and dyspnea
atelectasis
collapsed lung; incomplete expansion of alveoli
bradypnea
an abnormally slow rate of respiration usually of less than 10 breaths per minute
Bronchioles
Airways in the lungs that lead from the bronchi to the alveoli.
bronchitis
inflammation of the bronchi with partial obstruction of bronchi due to excessive mucus secretion
Bronchonphony
the spoken voice sound heard through the stethoscope, which sounds soft, muffled and indistinctive over normal lung tissue
bronchovascular
normal breath sound heard over major bronchi, characterized by moderate pitch and an equal duration of inspiration and expiration
chronic obstructive pulmonary disease (COPD)
permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema
Cilia
hairlike cells lining the tracheobronchial tree
Consolidation
the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia
crackles
(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration
Crepitus
coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue
dead space
passageways that transport air but are not available for gaseous exchange (e.g., trachea, bronchi)
Dyspnea
difficult or labored breathing
Emphysema
chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles
fissure
the narrow crack dividing the lobes of the lungs
fremitus
a palpable vibration from the spoken voice felt over the chest wall
friction rub
a coarse, grating, adventitious lung sound heard when the pleurae are inflamed
hypercapnia
increased amount of carbon dioxide in the blood
Hyperventilation
increased rate and depth of breathing
Hypoxia
Low oxygen saturation of the body, not enough oxygen in the blood
intercostal space
space between the ribs
Kussmaul respirations
type of hyperventilation that occurs with diabetic ketoacidosis
orthopnea
ability to breathe only in an upright position
paroxysmal nocturnal dyspnea
sudden awakening from sleeping with shortness of breath
pecussion
striking over the chest wall with short, sharp blows of the fingers to determine the size and density of the underlying organ
Rhonchi
low-pitched, musical, snoring, adventitious lung sounds caused by airflow obstruction from secretions
Tachypnea
rapid, shallow breathing
Vesicular
refers to soft, low-pitched, normal breath sounds heard over peripheral lung fields
wheeze
high-pitched, musical, squeaking adventitious lung sound
xyphoid process
sword like pointy process- cartilage when young. turns to bone as we age
This tool is used to check air and bone conduction hearing loss or to make sure your musical instrument is at the proper pitch...
tuning fork
Used for the weber and Rinne test
when performing this test your head is 30-60 cm away from the client and it is imperative they do not see your lips when you say several two syllable words...
Whisper test
This type of infection cause fever, pain and even purulent drainage if the eardrum is ruptured...
otitis media
this condition is when a newborn's tongue is attached too close to the floor of the mouth. Contrary to its name, it is not the connection from the leg to the foot.
Ankyloglossia
Aka tongue tied
this assessment finding manifest as a central gray opacity and negatively affects vision
Nuclear cataract
The congenital defect is displayed when the lip and or palate do not properly close
Cleft lip or cleft palate
decreased overall pupil size in the elderly is common but this is an unexpected and abnormally pupillary finding in this population
Unequal pupillary constriction
this patient behavior is a sign of hemorrhage following a tonsillectomy
frequent swallowing
These are classic signs of allergies
clear nasal drainage, eyelid creasing and transverse line across the the bridge of the clients nose
the result of cranial nerve III damage is ptosis, which manifest in this specific way...
the drooping of the upper lid
this is an infected hair follicle that is painful
furuncle
an inherited recessive X-linked trait affecting about 8% of white males and 4% of african american males and is checked between age 4-8 is....
colorblindess
this finding in newborn related to weak eye muscle may concern new parents but it will usually go away after three months without intervention
eye crossing
unlike otitis media, this infection may cause erythema and edema
otitis externa
this is a condition in which the eyes are not aligned together when looking at an object and is caused by the lack of eye muscle strength..
strabismus
this is the procedure used for assisting pupillary light reflex
shining a penlight across the pupil from the side
precuts excavatum
a chest that is hollowed out
barrel chest
anteroposterior = transverse diameter
suprasternal notch
Hollow, U-shaped depression just above the sterum, in between clavicles
Sternal Angle (Angle of Louis)
the articulation of the manubrium and the body of the sternum
shortness of breath and pleural pain commonly after having anesthesia, opioids or pain medicine
aletectasis
stridor, wheezing and sometimes and ear infection
bronchitis
symptoms include low grade fever, night sweats and weight loss, blood in sputum and may be blood streaked
turburculosis
pharyngitis, intermittent fever and eye discharge
Common cold or rhinoritis
nasal discharge, headache and cough
influenza
these lung sounds are high pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord) and predominate in expiration but may occur in both expiration and inspiration
high pitch wheezes
this lung sound has a very superficial sound that is both coarse and low pitch it has a breathing grading quality of tow pieces of leather are rubbing together
pleural friction rub
this lung sound is loud with low pitch bubbling and gurgling sounds. this is in early inspiration and may be present in expiration.
crackles
high pitch monophonic inspiratory crowning sounds that are louder in the neck than over the chest wall
stridor
stridor
Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
the lung sounds are continuous rumbling snoring or rattling sounds resulting from fluid or mucus
Rhonchi
rhonchi (singular: rhonchus)
loud rumbling sounds heard on auscultation of bronchi obstructed by sputum
sighs
breath of deep inspiration and prolonged expiration
this respiratory pattern unusually deep but regular breaths
kussmaul's respiration
Kussmaul respirations
very deep, labored breathing (usually associated with diabetic acidosis and renal failure)
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